Social work and the NICE guidance in palliative care - 1

Social work and the NICE Guidance on palliative care

Abstract
The guidance published by the UK National Institute for Clinical Excellence (NICE)
on improving palliative and supportive care for adults with cancer is analysed, as a
case study of the treatment of social work, social care and social issues from the
perspective of a healthcare organisation, in the context of the incorporation of social
care into healthcare provision in the UK. A quantitative analysis of word occurrences
demonstrates inclusion of social issues, but an aggregation of social care with health
care and of social support with psychological, spiritual and other forms of non-
medical provision. Examination of the guidance Manual and its supporting Evidence
and Economic reviews discloses coverage but limited articulation of social work and
social care roles, while use within the documents of several professional and status
distinctions make it hard to understand the integration of service as multiprofessional
and holistic. Professional social work bodies and social workers need to identify and
promote the particular contribution of social work and social care, while also showing
how these are integrated into a multiprofessional service.
 Social work and the NICE guidance in palliative care - 2

Social work and the NICE Guidance on palliative care

Malcolm Payne, Director, Psycho-social and Spiritual Care, St. Christopher’s
Hospice, 51-59 Lawrie Park Road, Sydenham, London SE26 6DZ
Email: m.payne@stchristophers.org.uk Telephone +44 208768 4500

Introduction: the NICE Guidance on palliative care

In 2004, the UK National Institute for Clinical Excellence (NICE; now merged to
form the National Institute for Health and Clinical Excellence), published guidance on
‘improving supportive and palliative care for adults with cancer’ (NICE, 2004). It was
intended to ‘define the service models needed to ensure that patients with cancer, their
families and others carers receive support to help with cancer and its treatment’
(NICE 2004: 15). NICE is ‘the independent organisation responsible for providing
national guidance on the promotion of good health and the prevention and treatment
of ill health’ (NICE, 2005). Its guidance is regarded as an authoritative standard for
UK National Health Service (NHS) provision, and is intended to assist NHS
commissioners and service providers plan through local partnerships the services in
their area. It was produced by a working party, after extensive consultations with
organisations and professions represented in the field. The Guidance Manual is
supplemented by two documents: a literature review, the Research Evidence (Gysels
and Higginson, 2004) and an Economic Review (Ward et al., 2004), which costed the
implementation of the Guidance. Thus, the Guidance represents an authoritative
research-based and costed model of health and social care provision in an important
specialty relevant to social work and social care.

The aim of this paper is to examine critically the treatment of social work in the NICE
Guidance on palliative care, as a case study of social work’s treatment in a research-
based healthcare policy and practice document in a multiprofessional specialty. The
analysis offers an indication of how social work stands in the context of UK official
policy-making, and how professions such as social work are affected by the use of
research evidence in health care decision-making. This is important, because
government policy is to incorporate social work into major public services such as the
NHS and education. Palliative care is a positive service context for incorporating
social work because of its multiprofessional ethos, whose conception explicitly
requires social work participation (Saunders, 2001), this paper asks how the
authoritative professional and service guidance incorporates social work into
palliative care.

Method
A search for a number of relevant terms was carried out on the main guidance
document, the manual and the evidence and economic reviews. The aim of these
searches was to provide a quantitative measure of the emphasis of the documents on
discussion of these subjects. The outcome is reported in Table 1 and the discussion is
contained in the next (third) section. Using these searches, an analysis of the
discussion on social work, social care, psychosocial issues and social support was
then undertaken. The argument of the Manual, followed by selected material in the
Evidence and Economic reviews were summarised in turn, in the fourth section of this
paper, followed by a discussion section. Conclusions are discussed in the final section.
 Social work and the NICE guidance in palliative care - 3

Occurrence of terms
The terms ‘social work’, ‘social worker’, ‘social care’, ‘social support’ (a term used in
the documents) and ‘psychosocial’ (with and without a hyphen – an omnibus term
often used in health care to refer issues that include psychological and social sequelae
of health care conditions) and the word ‘social’ were used, then compared with the
terms ‘health care’ with and without a hyphen and ‘health’. Professional titles were
also searched for: ‘doctor’ and ‘medical’, ‘nurse’ and ‘nursing’ and ‘physiotherapy’.
The omnibus term, often used in official documents in the UK in the early part of the
21st century, ‘health and social care’ was also searched for.

Table 1 Instances of occurrence of terms in the documents

Search terms The Manual Research Evidence Economic Review
social work 5 15 1
social worker 5 32 19
social care 136 14 44
social support 24 40 12
social 271 210 107
health and social care 101 9 27
health 379 335 88
health care 72 100 17
healthcare 16 7 15
psychosocial 13 126 0
physiotherapy 4 9 3
nurse or nursing 64 272 81
doctor or medical 42 166 35

This discussion focuses on terms related to social care and social work; other terms
have been examined for comparison. ‘Social work’ and ‘social worker’ are not heavily
cited in the Manual, but there is a stronger usage in the Research Evidence, drawing
on social work literature, and in the Economic Review because there are many
references to staff costings. 74.2% of the usages of social care appear in the omnibus
term ‘health and social care’ in the Manual, 64% in each of the other documents, so
separate discussion of social care as a concept is not a strong feature of the
documents. The terms ‘social support’ and ‘psychosocial’ was more often used than
‘social work’ or ‘social care’ in the evidence review; possibly because the healthcare
focus of the research leads to an emphasis on the social elements of healthcare, rather
than separate professions and services.

‘Social’ and its derivatives are used extensively in the documents, although not as
much as ‘health’ and its derivatives; this suggests that social issues are being
incorporated in healthcare debate and guidance. Social work and social care receive
more mentions than another small profession contributing to palliative care,
physiotherapy, and compare well with usage of terms referring to nursing and
medicine, perhaps because a healthcare perspective is central to the documents, in
view of the responsibilities of its parent body.

The occurrence of terms in the documents confirms that, as might be expected, social
aspects of health care are important in the NICE Guidance Manual (NICE 2004) and
its supporting documents; social factors are not ignored. Social care and social work
 Social work and the NICE guidance in palliative care - 4

also have a reasonable place. The next two sections examine how social work and
social care arise, and how we may evaluate their treatment.

Social work and social care issues in the documents

The Executive Summary of the Manual provides an overview of its content. Of its 15
uses of the word ‘social’, six are of the omnibus term ‘health and social care
professionals’, making recommendations that do not differentiate between the two
groups. Three are of ‘psychological, social and spiritual care’, again an omnibus for a
group of non-medical aspects of care. Six mentions occur in the two paragraphs
summarising the ‘social support’ section of the Manual; these emphasise the impact of
the social consequences of cancer and the importance of ‘explicit partnerships’
between local health and social care services and ‘the voluntary sector’. Thus, this
section, likely to be influential with busy managers and professionals, does not
identify or differentiate the particular skills and contribution of social work and social
care services and relies on administrative co-ordination as the major thrust of its
recommendations.

The Manual text prior to Chapter 6 on ‘social support’ contains 67 references to the
word ‘social’, mostly omnibus usages of ‘health and social care’ and combinations
‘psychological, social and spiritual’ care. However, a section on specialism notes
(NICE 2004a: 22) as an example that local authority social workers are generalists,
while hospice social workers are seen as specialist palliative care workers. Social
support is recommended as an integral part of palliative care, and social aspects are
recommended as important elements of assessment and communication.

Social work and social care are included in Chapter 5 on psychological support
services. This proposes a 4-level model of role and expertise. At level 1, it
recommends that all health and social care professionals should be able to recognise
psychological needs. At level 2 such professionals who are ‘designated’ and ‘with
additional expertise’ (NICE, 2004a: 78) should be able to screen patients for
psychological distress and engage in problem-solving; this include social workers
(NICE, 2004: 79). At level 3, ‘trained and accredited professionals’ (NICE 2004: 78)
should be able to screen for psychological distress and diagnose some
psychopathology, and provide counselling and specific psychological interventions
‘according to an explicit theoretical framework’ (NICE, 2004: 78). This includes ‘…
mild to moderate cancer-related concerns such as worries about treatment, personal
relationships (including sexual relationships), relationships with hospital staff and
spiritual issues.’ (NICE: 2004: 80). All of these areas would be the normal province of
social workers, but here are regarded as appropriate only for those with standing as
accredited counsellors using explicit frameworks such as anxiety management and
solution-focused therapy. Level 4 is reserved to ‘mental health specialists’ and
involves diagnosis of psychopathology and interventions such as cognitive-behaviour
therapy (NICE: 2000: 78). The American National Association of Social Workers
(NASW, 2005) argues that ‘…professional social workers are the [American] nation’s
largest group of mental health services providers. There are more clinically trained
social workers—over 190,000 in 1998—than psychiatrists, psychologists, and
psychiatric nurses combined’. The NICE recommendations on psychological support,
if they reflect a broader direction in official thinking on the role of social work, might
press the British social work profession to develop a similar argument about its
contribution to mental health.
 Social work and the NICE guidance in palliative care - 5

The evidence summary in the Manual (NICE, 2004: 83-4) acknowledges that there is
no evidence for the benefit of the four-level model, although elements of it have
achieved research support. The relevant Chapter of the Research Evidence review
(Gysels and Higginson, 2004: 115-48) shows that many of the studies provided group-
based psychosocial support, educational and problem-solving approaches by a variety
of personnel, including nursing and social work staff. Most results were mixed, and
the reviewers conclude:
Grade Ia [the best] evidence suggests that psychosocial
interventions with cancer patients are important for
enhancing coping and life quality for patients with cancer.
However, there is a need for caution. Psychotherapeutic
interventions are not beneficial per se. Different patient
groups with different types or stages of diseases have
different needs. Mainly grade Ib [the next best] studies
show that individually tailored interventions such as the
specialist nursing interventions or an interdisciplinary team
seem to have a positive impact on psychological and
physical functioning. The assessment of patient’s needs
deserves to be stressed in the recommendations. (Gysels
and Higginson, 2004: 119).

Of the 25 individual studies reviewed, that is not the meta-analyses, five (20%)
involved a social worker, eight (32%) by nurses, and three (12%) psychologists or
psychiatrists; not all the study summaries indicate the professional identity of the
therapist and some of these overlap. However, this shows that the review refers
mainly to support designated as psychological, without regard to the profession of the
worker, and the research reviewers focus on ‘psychosocial’ is interpreted as
psychological, excluding the social. This is an example of how the professional
divisions by which the chapters are organised discounts the complexity of the
multiprofessional service.

The main Chapter focusing on social issues is Chapter 6 on ‘Social Support’. It has
central importance for the Manual’s conception of the role and contribution of social
work and social care, containing 71 mentions of the word ‘social’, 26.1% of the total
in the document, but only one mention each of ‘social work’ and ‘social worker’ in the
text; two mentions appear in the citations. Social support is listed as:
 emotional support;
 help with personal care, such as bathing and dressing;
 advice on work and employment issues and assistance with
 financial support;
 help inside and outside the home;
 practical aids;
 help to care for children and other dependants (NICE, 2004: 86).

Social care is described as:

 practical help;
 personal care for patients;
 preservation or enhancement of social networks;
 Social work and the NICE guidance in palliative care - 6

 emotional support;
 income maintenance;
 provision of information on local and national resources;
 access to safe living environments which comply (at least) with minimum
standards;
 provision of respite care (NICE, 2004: 86-7).

The Manual recognises (NICE, 2004: 87) that much of this is wholly or partly
provided outside the NHS and focuses on collaboration with users, carers, social
services and voluntary agencies. It emphasises the local cancer networks as important
places for co-ordination and planning, although these rarely include social care
agencies. The services needed are listed as:
 practical support, including personal and domestic care;
 support to maintain independent living;
 support to maintain employment status;
 access to information and assistance in welfare rights;
 services to assess the needs and protect the rights of vulnerable adults or
children of a family member who has cancer, and to support people with
cancer in caring for vulnerable adults or children;
 respite and day care in social and health care settings;
 care home placements;
 support for carers, including emotional and practical support.

A summary of the evidence (NICE, 2004: 92-3) notes evidence that patients report
unmet needs in managing their family lives, emotions and changes in social identity,
and the absence of outcome studies assessing service that seek to provide such help.
However, there is evidence for the effectiveness of a palliative care multiprofessional
team model in providing care, for the presence of a ‘dedicated’ (i.e. specifically
allocated) social worker as part of the team in providing emotional support and for the
involvement of volunteers. The evidence summary refers to the need to evaluate
effective models for providing social care services, particularly barriers to patients
accepting use of the services. A summary of resource implications refers to the
importance of providing detailed ‘…social care assessments and welfare benefits
advice by social workers…’ (NICE, 2004: 93). All this suggests that social workers
should be a part of palliative care teams, but does not specifically connect this to the
evidence that social issues in patients’ lives are not tackled or point to the need to
develop those elements of the social work and social care roles identified that would
respond to this need.

The two supplementary reviews show where these comments come from. The social
support Chapter of the Evidence Review (Gysels and Higginson, 2004: 149-70)
contain 40 mentions of the word ‘social’, 19% of the total in the document. The
equivalent Chapter in the Economic Review (Ward et al, 2004: 33-7) contains 56
mentions of the word ‘social’, 52% of the total in the document.

Most of the studies were about home care services provided

primarily by nurses, in which multiprofessional work, with a key-
worker for effective information provision to the family, was
recommended. However, one study (Allison, et al, 1983) specifically
 Social work and the NICE guidance in palliative care - 7

examined a social work service, and defined the social worker’s role
in palliative care as:
 identification of problem areas in the patient’s present life
situation;
 sharing relevant information concerning the patient with his
family within the limits of confidentiality;
 liaison with community resources to provide necessary
supplies and equipment for home care;
 assisting the patient in purposeful planning for living;
 helping the family to deal with disrupted relationships;
 helping the patient with dysfunctional emotional reactions
to illness (Gysels and Higginson, 2004: 150).

The Economic Review (Ward et al, 2004) tries to cost the social support that Manual
recommends for the population of a typical cancer network with £1.5m population
and average needs. There are a number of exclusions. For example, social support
straddling local authority social services and the voluntary sector are not costed (Ward
et al, 2004: 5), the cost implications for local authorities of better information to
patients, identified as ‘potentially substantial’ (Ward et al, 2004: 12), are not
calculated, and the recommendation to support user and mutual support groups, said
to have typical costs between £10,000 and £60,000 a year (Ward et al, 2004: 15) were
also excluded due to lack of information. Social support is costed by examining three
elements of the service:
 the social work element of a specialist palliative care team;
 providing welfare rights advice;
 training for other healthcare workers on the social elements of carrying out
a front-line assessment.

The functions of social workers in palliative care are identified (the document like the
Manual does not say where this information comes from, but it does not seem to be
the evidence review) as follows:
 social care assessments;
 welfare rights advice;
 bereavement counselling;
 general counselling;
 professional psychological assessment, intervention, and support;
 care of families and children.
It is claimed that only social workers can do most social care assessments, and
provide welfare rights advice, while other health care professionals might provide
some of the rest. Therefore, costs are only assessed for the first two functions. This
exclusion means that major functions in relation to family support, said by the
evidence to be poorly provided, are not costed, and assumed to come from the general
resources for palliative care services. For social work, these are: 0.8 whole-time
equivalents per 17 in-patient beds, 1.5 sessions per 20-place palliative day centre, 0.8
whole-time equivalents per million population and 1.6 whole-time equivalents per
300 bereavement service clients.

The costing continues by assuming that 50% of specialist palliative care patients will
require a social care assessment or welfare rights advice; no source is given for this
 Social work and the NICE guidance in palliative care - 8

assumption. Five hours is taken as an average time to make an assessment on the

advice of a single social care advisor to the team, and the possibility of welfare rights
advice is lost at this point of the calculation. An average cancer network will require
4.3 whole-time equivalent social workers to do this number of hours work for the
average numbers of patients, and this is costed at a salary in 2001 of £22,557.00. This
is probably an inadequate level, taken from an adult services social worker costing by
the University of Kent Personal Social Services Research Unit (Ward et al, 2004: 37),
since many social workers in specialist palliative care have substantial experience and
are paid at local authority principal officer rates.

Another element of the costing is the assumption that all healthcare professionals will
need to be trained, with the involvement of social care professionals, to make
frontline assessments, and costs are allocated for this in the initial training
requirements for the implementation of the guidance, but ‘…after completion of
training, these assessments will become resource neutral, in the sense that no extra
staff will be required and the assessments will become part of normal working
practice’ (Ward et al, 2004: 34). The assumption that there will be no ongoing training
needs in social care for a healthcare workforce that is constantly changing and
inadequate in numbers seems imprudent.

There is a separate costing for bereavement services, many of which are part of social
work services in specialist palliative care. The costing is neutral about whether the
service is provided as part of a social work team or by general bereavement services
in the community, but makes provision for organisation, administrative support and,
included in the estimate for specialist palliative care reported above, for social
workers or others providing bereavement counselling. The costing also notes that
some social workers will be proving psychological assessment and care, largely at the
lower (non-expert) levels of provision.

Chapter 7 of the Manual (NICE, 2004: 95-104) follows that on social support and to
some degree interlocks with it. It argues that spiritual issues may arise when
emotional and social consequences of cancer have an impact on patients, sees spiritual
care as part of a holistic model of care, and family and social support interacting with
spiritual care. It uses a four-level model of competence in providing care, similar to
that used in the psychological support chapter discussed above, culminating in Level
4 professionals whose primary responsibility is spiritual and religious care. Level 3
staff includes social workers.

The two following Manual chapters on general and specialist palliative care include
social workers as part of the service and social support and care as crucial to the
provision. Most of the references to social care are to omnibus statements, in which
social care is included in broader statements about services. Chapter 10 on
rehabilitation services refers primarily to allied health professions, and contains only
one mention of health and social care professionals. However, among the
professionals mentioned are ‘psychosexual counsellors’ and assessment of self-care,
coping at home and work and leisure activities is recommended. While these might all
be provided as part of a social work service, the healthcare focus of the Manual leaves
this possibility unacknowledged. Again, a four-level model of competence is
described; referring on this occasion to allied health professionals. Chapter 11 is about
complementary therapies.
 Social work and the NICE guidance in palliative care - 9

Chapter 12 covers services for families and carers and bereavement services, and
contains 21 mentions of the word ‘social’. Most of these are again to the omnibus
phrases including social care. The Carers (Recognition and Services) Act 1995 is
mentioned alongside guidance to ensure that a separate carers’ assessment is obtained.
Health and social care professionals ‘providing day-to-day care to patients’ (NICE,
2004: 159) should also address the needs of family members and carers, although the
evidence summary says that carers ‘…report high satisfaction with…[home care
services]… in helping them to look after patients, but they do not meet many of the
carers’ own needs’. (NICE, 2004: 163). Bereavement services are analysed according
to a three-component model, the first component being informal care and the second
component volunteer and community groups. The third component of ‘specialist
interventions (NICE, 2004: 161) refers to mental health, psychological support,
counselling/psychotherapy, specialist palliative care and general bereavement
services, does not mention social work or social care services. Providing separate
assessments for carers, addressing the needs of families and providing bereavements
support are all areas that might be regarded as central to a conception of social work
in palliative care, yet there is no differentiation of social work or social care from
other health care services in this Chapter of the Manual.

Chapter 13 reviews directions for future research, and recommends a focus on

outcome and effectiveness studies, rather than continued examination of needs. It
proposes that studies of effectiveness should make clear the configuration of services
assessed. It does not separately deal with social care, treating it as ‘health and social
care’.

Discussion
The aim of this paper has been to analyse an authoritative specialist NHS document
giving professional guidance on palliative care for cancer patients, an area recognised
to have profound social implications. The purpose of doing so is to identify evidence
for trends in thinking about the relationship of health and social care and consider
possible consequences for the role of social work as part of palliative care. Extending
from that, the analysis shows the consequences for social work, viewed as a
professional discipline and workforce, of such trends in thinking and analysis of
healthcare work.

The method of analysis started with a search for particular terms to indicate
quantitatively the importance given in them to social concerns, using occurrences of
the word ‘social’ as a proxy for the importance given to overall social issues and
professional terms to identify the coverage of social work, and, as comparators,
healthcare, nursing, medicine and physiotherapy. This method may be limited, if
social issues were identified by other terms, but the electronic searches produced
outcomes that identified chapters focused on social issues and other appearances in
the text, which seem intuitively reasonable. A close reading of the texts did not
disclose other major social issues dealt with elsewhere, although a link is often not
made to issues where social work and social care services might be relevant. This
suggests that healthcare thinking may fail to identify social work and social care
contributions explicitly, while not being hostile. A summary of areas of the texts in the
documents referring to social issues, and in particular to social support, was used to
identify their argument on social issues and its basis.
 Social work and the NICE guidance in palliative care - 10

The occurrence analysis showed that the impact of social issues, social care and social
support were important in the discussion and recommendations. However, ‘social
care’ and ‘social support’ were often referred to as part of omnibus terms. Thus, no
clear differentiation of social care services or social work was made. This suggests
that there may be a risk of token inclusion of social care and social issues, without a
full examination of their particular role and needs. Moreover, NICE’s responsibilities
makes healthcare the starting point of the documents, a healthcare perspective may
colour the way social issues are presented. For example, it may not identify social
issues that are the consequence of healthcare priorities.

This can be seen in the Executive Summary, which brings together complex
commentary on social support in a single recommendation for co-ordination between
healthcare and social care agencies. Similarly, social issues are often presented as an
impact or consequence of ill-health, rather than a target for consideration and
intervention in their own right. The Chapter on families and carers, for example, notes
the evidence that palliative home care services provide good care for patients, but not
for their carers, but recommends a continuation of responsibility for both, offering no
robust guidance on the need for separate assessment of and support for carers. This
Chapter, unlike the rest of the guidance, relies strongly on mutual support and
volunteer work for the primary provision of services. Throughout, emotional,
psychological and social support are seen as adjuncts to the main focus of the service,
provided by all professionals in many cases, with a hierarchy of specialisation that
offers fully trained and experienced professionals only at the apex of need. The
Chapter on social support, on the other hand, does not explore how different levels of
support are to be provided, and the Economic Review restricts its costing of the
service that social workers should provide to a small proportion of its list of services,
leaving the rest, despite evidence that specifically social needs are not being met, to
provision by any health and social care professionals. This is a likely recipe for
ignoring social needs: anybody’s responsibility is often nobody’s responsibility.
Emotional care and care in the home is rightly noted as a component of several
professionals’ responsibility, for example as an important element of rehabilitation
work. However, this reflects an institutionalised focus on considering the complexity
of the role of healthcare professionals, without a similar differentiation of the role of
social care professionals.

Although it refers to palliative care as a holistic service, the document divides up the
service into domains that reflect particular professional or service interests. Thus, the
topic areas refer to some general issues, such as co-ordination of care, user
involvement, face-to-face communication and information provision, but most of the
chapters are proxies for professional interests: psychological support
(psychology/psychiatry), social support (social work), spiritual support (chaplains),
general palliative care (primary care), specialist palliative care (hospices and
specialist palliative care teams), rehabilitation (allied health professionals, especially
physiotherapists), complementary therapy, services for families and carers, including
bereavement services (voluntary sector and carer support agencies). While overlaps
and interlocking provision is acknowledged, the consequence is divided presentation
of palliative care that neither reflects the intention of the guidance to achieve a holistic
service, nor the evidence and costings, which reflect a much more integrated picture.
 Social work and the NICE guidance in palliative care - 11

A good example of the consequences of this arises in the multiple levels of

competence and professional contribution presented in psychological and spiritual
care, and the components of family, carer and bereavement care. In each case, the
assumption is that most health and social care professionals or services will be able to
identify problems, more competent professionals be able to make simpler
interventions, but that more complex interventions may be undertaken by the most
highly qualified and accredited professionals, who will assess and deal with only the
most complex situations. Moreover, it is acknowledged that there is no research
evidence for this four-level differentiation in the case of psychological care, and
examination of the research into ‘psychosocial care’, which underlies the evidence of
effectiveness shows that nurses, social workers and a range of professionals and
volunteers provided information, problem-solving and educational interventions, and
in some cases psychology professionals used formal interventions. The ‘social’ has
been removed from an analysis that focuses on the psychological, while the
psychological is removed from the discussion in the Chapter on social support.

The picture in the research is of a gradient or range of provisions, rather than the
guidance manual’s recommendation of a service based on professional and status
divisions. Consequently, a more realistic recommendation might be multiprofessional
consultation, peer support and supervision among professionals and shared work,
rather than a hierarchical and professional division. This division of the guidance into
professional and service interests for purposes of analysis does not reflect either user
requirements and service provision or the research finding of the importance and
effectiveness of multiprofessional work.

Another consequence of this division of complex services into professional elements

comes out in the treatment of social support in the Economic Review (Ward et al,
2004), where there are overlapping elements of psychological, family and
bereavement and social care that are hard to disentangle. The costing work also
illustrates how the availability of such ‘best-available’ analyses may mislead policy
and service development. Substantial elements of provision are excluded from the
costing study, which appears to be based on minimal evidence, while assumptions
about the complexities of providing a service are acknowledged only in the detail of
the text. Consequently, managers looking at the overall costing at a global level might
easily make inadequate financial provision.

The NICE palliative care guidance thus acknowledges but does not integrate
important psychological and social elements, and at the same time its healthcare focus
does not differentiate the requirements of social work and social care. Different
accounts are given, without sources, in the Manual and the Economic Review of the
content of social care services, and one of few studies to outline the actual role of
social work in a service, discussed in the Research Evidence, is not picked up.
Consequently, the particular service, knowledge and skill development requirements
for a palliative care social work service are not authoritatively set out because the
focus is on the elements of a total palliative care service, irrespective of the
professional groups providing it. The same also applies to psychology and spiritual
care. The paradox is that the potential roles of social work and social care, within
palliative care services as a whole, are not identified at the same time as the
disaggregation of the elements of the service also makes it hard to see it as a whole.
 Social work and the NICE guidance in palliative care - 12

Conclusion
In summary, the NICE guidance on palliative care provides a useful case study of the
way in which social care has been treated in a health care specialty where the social
impact of illness is crucial. Social issues are appropriately included. However, the
assumptive world of the documents make healthcare its starting point and social care
and social support are often aggregated with aspects of service outside the main focus,
especially with psychological care. This aggregation makes it difficult to disentangle
and give priority to specifically social, social care and social work issues within
service organisation and costing work. On the other hand, a focus in the guidance on
specific elements of the overall service does not show how a holistic service might be
achieved through multiprofessional integration and tends to create recommendations
divided along professional and status lines.

How could social care and social work organisations respond to this? One way,
demonstrated by the American national social workers’ organisation in mental health,
is to identify and promote the greater understanding of role of social work in different
services. For example in palliative care, it should be possible to achieve greater
awareness of the role of social work in psychological care, for which there is clear
evidence. On the other hand, the only valid service for most users is a
multiprofessional one, so it is also important for the social work profession to identify
the elements of social provision in specialist areas of provision, such as palliative
care, and how it may be integrated effectively into multiprofessional care.

Acknowledgement
Some parts of this paper are based on the Frederic Seebohm Memorial Lecture, given
by the author in November 2004 at the University of Southampton, and a paper for the
South-West London Palliative Care Guidance Implementation Group.

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